The Nursing Process and Clinical Assessment Techniques

Nursing Process

A structured framework to guide clinical thinking and decision-making, helping students systematically assess clients, identify priorities, develop care plans, implement interventions, and evaluate outcomes.

Phases of the Nursing Process

Assessment, diagnoses, outcome identification, planning, implementation, evaluation.

Ongoing Evaluation of Plans of Care

Ensures that the care plan remains relevant and effective in meeting the client's evolving needs, helping identify whether goals are being met, whether interventions are working, and if modifications are needed.

Ongoing Evaluation of Personal Clinical Practice

Fosters self-awareness, accountability, and professional growth.

Diagnostic Reasoning

Attending to cues, formulating hypotheses, gathering data, evaluating hypotheses + data.

Purpose of the Nursing Process

A systematic, dynamic, and client-centered method nurses use for delivering care.

Characteristics of the Nursing Process

Promotes collaboration and communication, encourages patient participation, dynamic and cyclic, requires critical thinking and clinical reasoning, ensures continuity and coordination of care, improves job satisfaction, universally applicable, promotes individualized care and evidence-based care, cost effective.

Independent Nursing Practice

The nursing process allows nurses to independently assess, diagnose, plan, implement, and evaluate care based on patient responses—not just medical diagnoses.

Qualities Needed by Nurses

Critical thinking and analytical skills, effective communication, creativity and intuition, empathy and compassion, organizational and time management skills, cultural sensitivity and non-judgmental attitude, commitment to evidence-based practice and continuous learning.

Health Assessment

A systematic method of collecting and analyzing data about a client's physical, psychological, sociocultural, developmental, and spiritual health status; it is the foundation of the assessment phase in the nursing process.

Purposes of Health Assessment

Identify patient strengths and actual/potential health problems, develop an accurate and individualized care plan, monitor changes in health status, provide a baseline for evaluating interventions and outcomes, promote wellness and early detection of health issues.

Health Assessment Processes

Observation, interviewing, physical examination, review of health records, ongoing vs initial assessments.

Observation in Health Assessment

Systematic use of senses to gather data.

Interviewing in Health Assessment

Purposeful communication to gather subjective data.

Physical Examination

Objective data through inspection, palpation, percussion, auscultation.

Review of Health Records

Includes past history and secondary data.

Ongoing vs Initial Assessments

Comprehensive vs focused assessments over time.

Nursing Frameworks

Gordon's Functional Health Patterns is a framework that organizes assessment data into 11 categories such as nutrition, sleep, activity, self-perception, coping, and more.

Jarvis' health assessment framework

A structured approach to holistic and systematic nursing assessment.

Biographical data

Information about the patient's personal history and background.

Present illness (PQRSTU)

A method for assessing current health issues, focusing on Provocation, Quality, Region, Severity, Timing, and Understanding.

Cultural assessment

An evaluation of a patient's cultural background, beliefs, values, and social determinants of health.

Social determinants of health

Factors such as poverty and discrimination that affect health outcomes.

Data collection

The process of gathering information through observation, interviews, and physical assessment.

Interpretation of data

The analysis and conclusion drawn from collected data to identify patterns and plan care.

Nursing diagnosis

Focuses on human responses to health conditions that nurses can treat independently.

Medical diagnosis

Identifies diseases or conditions made by physicians or nurse practitioners.

Systems approach

A framework that assesses each body system to organize health assessment data.

Gordon's Functional Health Patterns

A framework that assesses broader aspects of health like nutrition, sleep, and coping.

Diagnostic reasoning process

A critical thinking process used to collect, interpret, and analyze data to formulate nursing diagnoses.

Present health status

Includes client strengths, wellness diagnosis, actual, potential, and possible nursing diagnoses.

Health problem

A maladaptive human response to a health condition, manifesting as physical symptoms or emotional distress.

Collaborative problems

Complications requiring both nursing and medical interventions.

Nurse's role in collaborative problems

Recognize the problem, monitor changes, and implement protocols or medical orders as needed.

Diagnostic statements

A format used to write nursing diagnoses based on health assessment data.

Functional assessment (ADL'S)

An evaluation of a patient's ability to perform activities of daily living.

Cultural safety and competence

Practicing inclusivity and respect for diverse cultural backgrounds in healthcare.

Non-judgmental approach

Being inclusive and respectful, especially towards Indigenous and 2SLGBTQI+ populations.

Recognizing data gaps

Identifying missing information that is crucial for accurate assessment and diagnosis.

Formulating hypotheses

The process of creating potential explanations based on collected data.

Actual diagnoses

Current health problems identified through assessment with signs and symptoms.

Potential (risk) diagnoses

Problems that are likely to develop without intervention.

Possible diagnoses

Suspected health issues that require further data for confirmation.

Nursing diagnosis format

Problem (NANDA label), related to (etiology/contributing factor), as evidenced by (subjective/objective data)

Example of nursing diagnosis

Constipation related to inactivity as evidenced by hard stools and straining with bowel movements

Physiology of the head and neck

Includes cranial bones, facial muscles, salivary glands, and the thyroid gland; contains vital structures: blood vessels, muscles, lymph nodes, and the trachea.

Lymphatics

Includes chains of lymph nodes: preauricular, posterior auricular, occipital, submandibular, submental, cervical, and supraclavicular; filters lymph and detects infections/inflammation.

Eyes anatomy

Composed of external structures (eyelids, lashes, conjunctiva), extraocular muscles (controlled by CN III, IV, VI), and internal structures (lens, retina, optic nerve).

Eyes functions

Includes accommodation, light reflexes, and visual processing.

Ears anatomy

Divided into external, middle, and inner ear.

Ears functions

Involved in hearing (via air and bone conduction) and balance (via semicircular canals and vestibule).

Subjective data for head/neck/lymphatics

Headaches, trauma, dizziness, neck stiffness or pain, lumps, previous surgery; for infants: prenatal exposures, delivery type, growth pattern.

Subjective data for eyes

Vision changes, pain, redness, discharge, history of glaucoma, corrective lenses, medications.

Subjective data for ears

Earaches, discharge, hearing loss, exposure to noise, tinnitus, vertigo, infections, ear care habits.

Systematic assessment of head

Inspect and palpate skull shape (normocephalic), temporal artery, TMJ, facial symmetry.

Systematic assessment of neck

Inspect and palpate lymph nodes, trachea position, thyroid gland (posterior/anterior approach), auscultate for bruits.

Systematic assessment of eyes

Visual acuity (Snellen), visual fields, extraocular muscle function (corneal light reflex, cover test, 6 positions), inspect external structures, use ophthalmoscope for fundus.

Systematic assessment of ears

Inspect/palpate external ear, perform otoscopic exam (tympanic membrane color, integrity), assess hearing (whisper test, tuning forks), perform Romberg for balance.

Expected normal findings for head/neck

Skull is round, normocephalic, no tenderness; face is symmetrical; lymph nodes are non-palpable or soft, mobile, non-tender; thyroid not visibly enlarged; no bruits.

Expected normal findings for eyes

Symmetrical movement, pupils equal and reactive to light (PERRLA), clear conjunctiva, red reflex present.

Expected normal findings for ears

External ears aligned, no lesions; tympanic membrane is pearly gray and intact; hearing intact to normal voice tones, good balance on Romberg test.

Nursing diagnoses for head/neck/lymphatics

Impaired physical mobility (neck) related to pain and stiffness; risk for infection related to open wounds or recent surgery; disturbed body image related to visible head/neck abnormalities.

Nursing diagnoses for eyes

Impaired visual sensory perception related to macular degeneration or cataracts; risk for injury related to decreased vision; self-care deficit due to vision changes.

Nursing diagnoses for ears

Impaired hearing related to sensorineural loss; disturbed sensory perception (auditory) related to tinnitus; social isolation related to hearing impairment.

Gas exchange

Oxygen intake and carbon dioxide removal.

Control of respiration

Mediated by the brainstem in response to CO₂/O₂ levels.

Inspiration

Active process—diaphragm and intercostal muscles contract, increasing thoracic volume.

Expiration

Usually passive—muscles relax, decreasing thoracic volume.

Respiratory structures

Nasal cavity, sinuses, pharynx, larynx, trachea, bronchi, lungs, alveoli.

Acinus

Functional respiratory unit including bronchioles, alveolar ducts, alveolar sacs, and alveoli.

Subjective data for respiratory assessment

Includes cough, shortness of breath, chest pain with breathing, history of respiratory infections, smoking history, environmental exposure, self-care behaviors.

Additional questions for infants/children

Illness frequency, allergies, chronic conditions, environmental smoke exposure.

Additional questions for older adults

Activity tolerance, lung disease history, pain, and smoking habits.

Nose assessment

Inspect/palpate external nose and nasal cavity; use an otoscope to examine nasal septum and turbinates.

Sinuses assessment

Palpate frontal and maxillary sinuses for tenderness.

Mouth assessment

Inspect lips, teeth, gums, tongue (cranial nerve XII), buccal mucosa, palate, uvula.

Throat assessment

Inspect tonsils (graded 1+ to 4+), posterior pharyngeal wall.

Thorax and lungs assessment

Inspect thoracic cage, symmetry, skin; palpate for symmetrical expansion and tactile fremitus; percuss for resonance; auscultate for breath sounds and adventitious sounds (crackles, wheezes, etc.).

Nursing diagnoses for altered respiratory function

Ineffective airway clearance, impaired gas exchange, ineffective breathing pattern, risk for aspiration, activity intolerance related to respiratory compromise, impaired spontaneous ventilation.

Expected findings in respiratory examination

Nose & sinuses: Patent nares, no tenderness on sinus palpation; Mouth & throat: Pink, moist mucosa; tonsils 1+ or absent; no lesions; Thorax and lungs: Symmetrical chest expansion, resonant percussion sounds, breath sounds: Bronchial (trachea), Bronchovesicular (major bronchi), Vesicular (peripheral lungs), no adventitious sounds (crackles, wheezes, etc.).

Heart physiology

A muscular pump with four chambers (two atria, two ventricles) that pumps blood through the pulmonary (lungs) and systemic (body) circuits.

Blood flow through the heart

RA → RV → lungs (via pulmonary artery) → LA → LV → body (via aorta).

Cardiac cycle

Systole (contraction), Diastole (relaxation).

Electrical conduction in the heart

SA node → AV node → Bundle of His → Purkinje fibers.

Peripheral Vascular System

Arteries carry oxygenated blood away from the heart; veins return deoxygenated blood to the heart; lymphatic system supports immune function and fluid balance.

Major risk factors for cardiovascular disease

Hypertension, smoking, high serum cholesterol, obesity, diabetes, socioeconomic status influences outcomes.

Heart Inspection

Precordium and apical impulse examination.

Heart Palpation

Assessment of apical impulse, thrills, and lifts/heaves.

Heart Auscultation

Listening at 5 valve areas (APE To Man) to identify S1 and S2, noting rate, rhythm, murmurs, and extra heart sounds (S3, S4).

Neck Vessels Palpation

Palpate carotids one at a time.

Neck Vessels Auscultation

Auscultate for bruits.

Jugular Venous Pulse Inspection

Inspect jugular venous pulse and estimate jugular venous pressure.

Peripheral Vascular Inspection

Inspect and palpate arms and legs for skin, hair, symmetry, temperature, and capillary refill.

Peripheral Pulses Palpation

Palpate radial, brachial, femoral, popliteal, dorsalis pedis, and posterior tibial pulses.

Edema Check

Check for edema and lymph node enlargement, using grading scales (1+ to 4+).

Modified Allen Test

Special test for assessing blood flow to the hand.

Ankle Circumference Check

Measurement of ankle circumference.

Subjective Data: Chest Pain

A symptom included in a comprehensive health history.

Subjective Data: Dyspnea/Orthopnea

A symptom included in a comprehensive health history.

Subjective Data: Cough

A symptom included in a comprehensive health history.